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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - SPOTLIGHT CASE
A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion
Citation Text:
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
Susan S. Huang, MD, MPH | March 1, 2014
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Citation Text:
Huang SS. How Does Infection Prevention Fit Into a Safety Program?. PSNet [interne…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/web-mm/2-week-itch
June 16, 2019 - The 2-Week Itch
Citation Text:
Cohen MR. The 2-Week Itch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
Citation Text:
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Are We Pushing Graduate Nurses Too Fast?
Citation Text:
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety
Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023
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Citation Text:
Stanley J, Ga…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
Contact
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…